Assessing the Benefits and Harms Associated with Early Diagnosis from the Perspective of Parents with Multiple Children Diagnosed with Duchenne Muscular Dystrophy

Duchenne muscular dystrophy (DMD) is a rare neuromuscular disorder diagnosed in childhood. Limited newborn screening in the US often delays diagnosis. With multiple FDA-approved therapies, early diagnosis is crucial for timely treatment but may entail other benefits and harms. Using a community-based survey, we explored how parents of siblings with DMD perceived early diagnosis of one child due to a prior child's diagnosis. We assessed parents' viewpoints across domains including diagnostic journey, treatment initiatives, service access, preparedness, parenting, emotional impact, and caregiving experience. We analyzed closed-ended responses on a -1.0 to +1.0 scale to measure the degree of harm or benefit parents perceived and analyzed open-ended responses thematically. A total of 45 parents completed the survey, with an average age of 43.5 years and 20.0% identifying as non-white. Younger siblings were diagnosed 2 years earlier on average (p < 0.001). Overall, parents viewed early diagnosis positively (mean: 0.39), particularly regarding school preparedness (+0.79), support services (+0.78), treatment evaluation (+0.68), and avoiding diagnostic odyssey (+0.67). Increased worry was a common downside (-0.40). Open-ended responses highlighted improved outlook and health management alongside heightened emotional distress and treatment burdens. These findings address gaps in the evidence by documenting the effectiveness of early screening and diagnosis of DMD using sibling data.

Development and electronic health record validation of an algorithm for identifying patients with Duchenne muscular dystrophy in US administrative claims

BACKGROUND: Muscular dystrophies (MDs) comprise a heterogenous group of genetically inherited conditions characterized by progressive muscle weakness and increasing disability. The lack of separate diagnosis codes for Duchenne MD (DMD) and Becker MD, 2 of the most common forms of MD, has limited the conduct of DMD-specific real-world studies. OBJECTIVE: To develop and validate administrative claims-based algorithms for identifying patients with DMD and capturing their nonambulatory and ventilation-dependent status. METHODS: This was a retrospective cohort study using the statistically deidentified Optum Market Clarity Database (including patient claims linked with electronic health records [EHRs] data) to develop and validate the following algorithms: DMD diagnosis, nonambulatory status, and ventilation-dependent status. The initial study sample consisted of US patients in the database who had a diagnosis code for Duchenne/Becker MD (DBMD) between October 1, 2018, and September 30, 2020, who were male, aged 40 years or younger on their first DBMD diagnosis, and met continuous enrollment and 1-day minimal clinical activities requirement in a 12-month measurement period between October 1, 2017, and September 30, 2020. The algorithms, developed by a cross-functional team of DMD specialists (including patient advocates), were based on administrative claims data with International Classification of Diseases, Tenth Revision, Clinical Modifications coding, using information of diagnosis codes for DBMD, sex, age, treatment, and disease severity (eg, evidence of ambulation assistance/support and/or evidence of ventilation support or dependence). Patients who met each algorithm and had EHR notes available were then validated against structured fields and unstructured provider notes from their own linked EHR to confirm patients' DMD diagnoses, nonambulatory status, and ventilation-dependent status. Algorithm performance was assessed by positive predictive value with 95% CIs. RESULTS: A total of 1,300 patients were included in the initial study sample. Of these, EHR were available and reviewed for 303 patients. The mean age of the 303 patients was 14.8 years, with 61.7% being non-Hispanic White. A majority had a Charlson comorbidity index score of 0 (59.4%) or 1-2 (27.7%). Positive predictive value (95% CI) was 91.6% (85.8%-95.6%) for the DMD diagnosis algorithm, 88.4% (80.2%-94.1%) for the nonambulatory status algorithm, and 77.8% (62.9%-88.8%) for the ventilation-dependent status algorithm. CONCLUSIONS: This work provides the means to more accurately identify patients with DMD from administrative claims data without a specific diagnosis code. The algorithms validated in this study can be applied to assess treatment effectiveness and other outcomes among patients with DMD treated in clinical practice. DISCLOSURES: This study was funded by Pfizer, which contracted with Optum to perform the study and provide medical writing assistance. Ms Schrader reports being an employee of Parent Project Muscular Dystrophy. Mr Posner reports being an employee and stockholder of Pfizer and receiving support from Pfizer for attending conferences not related to this manuscript. Dr Dorling reports being an employee and stockholder of Pfizer at the time the study was conducted and is a current employee of Chiesi USA, Inc. Ms Senerchia reports being an employee of Optum and owning stock in Pfizer and UnitedHealth Group, the parent company of Optum. Dr Chen reports being an employee and stockholder of Pfizer. Ms Beaverson reports being an employee of Pfizer and owning stock in Pfizer and Amicus Therapeutics. Dr Seare reports being an employee of Optum at the time the study was conducted. Dr Garnier and Ms Merla report being employees of Pfizer. Ms Walker reports being an employee of Optum. Dr Alvir reports being an employee and stockholder of Pfizer. Dr Mahn reports being an employee and stockholder of Pfizer. Dr Zhang reports being an employee of Optum. Ms Landis reports being an employee of Optum. Ms Buikema reports being an employee of Optum and holding stock in UnitedHealth Group, the parent company of Optum.

Disease Progression Stages and Burden in Patients with Duchenne Muscular Dystrophy Using Administrative Claims Supplemented by Electronic Medical Records

INTRODUCTION

This study aims to identify stages of Duchenne muscular dystrophy (DMD) and assess the disease burden by progression stage using real-world administrative claims supplemented by relevant electronic medical record (EMR) data.

METHODS

Claims and EMR data from the Decision Resources Group's Real World Data Repository (2011-2020) were used to identify patients with DMD by diagnosis code and to stratify them into four disease stages by diagnosis and procedure markers reflective of DMD progression. Clinical and medical history data from the Cooperative International Neuromuscular Research Group (CINRG) were used to validate the developed claims-based staging algorithm. The distribution and drivers by disease stage, as well as disease burden, were examined.

RESULTS

A total of 938 (94%) of patients with DMD identified in claims/EMR data had sufficient information for stage classification. Patients were classified by stage based on patient characteristics and the presence or absence of progression markers such as genetic testing, wheelchair usage, scoliosis treatment, or ventilation assistance. Average ages at stages 1-4 are 7, 13, 18, and 23 years, respectively. Using natural history data, the claims-based staging algorithm was validated with high sensitivity and specificity rates. Both healthcare resource utilization and medical charges increased by stage. For example, the average annualized total charges were $17,688 (stage 1), $36,868 (stage 2), $72,801 (stage 3), and $167,285 (stage 4).

CONCLUSIONS

Large-scale claims data supplemented by EMR data can be used to characterize DMD progression and evaluate disease burden which may inform the design of future real-world studies about DMD.

Duchenne expert physician perspectives on Duchenne newborn screening and early Duchenne care

Duchenne muscular dystrophy (DMD) is a progressive, fatal neuromuscular disorder typically diagnosed between 4 and 5 years of age. DMD currently has five FDA approved therapies, which has led to increased interest in newborn screening (NBS) for DMD. Our objective was to explore the perspectives and predicted practices of physicians (primarily neurologists) who will likely be responsible for the follow-up of infants identified with DMD through NBS. A short survey was developed and distributed to physicians who are responsible for providing care for patients with Duchenne at Certified Duchenne Care Centers across the USA. Twenty-seven physicians responded to statements about benefit and readiness for dystrophinopathy NBS, which care recommendations they would make at initial infant visits, and when they would recommend initiating approved therapies. Most DMD physicians indicated they see benefit in NBS (82%) and believe the DMD care community is ready for NBS in dystrophinopathies (74%). The majority of physicians would recommend multiple interventions, including genetic counseling, maternal carrier testing, referral to early intervention services, screening siblings, discussion of clinical trials, exon skipping therapies, and assessment of social and language development at initial visits. The majority of physicians also indicated they would recommend initiating approved therapies much earlier than the typical age of diagnosis.

Truncating variants in UBAP1 associated with childhood-onset nonsyndromic hereditary spastic paraplegia

Hereditary spastic paraplegia (HSP) is a group of disorders with predominant symptoms of lower-extremity weakness and spasticity. Despite the delineation of numerous genetic causes of HSP, a significant portion of individuals with HSP remain molecularly undiagnosed. Through exome sequencing, we identified five unrelated families with childhood-onset nonsyndromic HSP, all presenting with progressive spastic gait, leg clonus, and toe walking starting from 7 to 8 years old. A recurrent two-base pair deletion (c.426_427delGA, p.K143Sfs*15) in the UBAP1 gene was found in four families, and a similar variant (c.475_476delTT, p.F159*) was detected in a fifth family. The variant was confirmed to be de novo in two families and inherited from an affected parent in two other families. RNA studies performed in lymphocytes from one patient with the de novo c.426_427delGA variant demonstrated escape of nonsense-mediated decay of the UBAP1 mutant transcript, suggesting the generation of a truncated protein. Both variants identified in this study are predicted to result in truncated proteins losing the capacity of binding to ubiquitinated proteins, hence appearing to exhibit a dominant-negative effect on the normal function of the endosome-specific endosomal sorting complexes required for the transport-I complex.

Diagnostic Utility of Whole Exome Sequencing in the Neuromuscular Clinic

Next-generation sequencing is a powerful diagnostic tool, yet it has proven inadequate to establish a diagnosis in all cases of congenital hypotonia or childhood onset weakness. We sought to describe the impact of whole exome sequencing (WES), which has only recently become widely available clinically, on molecular diagnosis in the Nationwide Children's Hospital Neuromuscular clinics. We reviewed records of all patients in our clinic with pediatric onset of symptoms who had WES done since 2013. Patients were included if clinical suspicion was high for a neuromuscular disease. Clinical WES was performed in 30 families, representing 31 patients, all of whom were seen for hypotonia, weakness, or gait disturbance. Probands had between 2 and 12 genetic diagnostic tests prior to obtaining WES. A genetic diagnosis was established in 11 families (37%), and in 12 patients (39%), with mutations in 10 different genes. Five of these genes have only been associated with disease since 2013, and were not previously represented on clinically available disease gene panels. Our results confirm the utility of WES in the clinical setting, particularly for genetically heterogeneous syndromes. The availability of WES can provide an end to the diagnostic odyssey for parents and allow for expansion of phenotypes.

Regional cerebral blood flow in children from 3 to 5 months of age

BACKGROUND AND PURPOSE

Understanding the relationship between brain and behavior in early childhood requires a probe of functional brain development. We report the first large study of regional CBF by use of arterial spin-labeling in young children.

MATERIALS AND METHODS

Cerebral blood flow by use of arterial spin-labeling was measured in 61 healthy children between the ages of 3 and 5 months. Blood flow maps were parcellated into 8 broadly defined anatomic regions of each cerebral hemisphere.

RESULTS

There was no sex effect; however, group analysis demonstrated significantly greater CBF in the sensorimotor and occipital regions compared with dorsolateral prefrontal, subgenual, and orbitofrontal areas (P < .0001). A significant age effect was also identified, with the largest increase in blood flow between 3 and 5 months occurring in the following regions: orbitofrontal (P < .009), subgenual (P < .002), and inferior occipital lobe (P = .001).

CONCLUSIONS

These results are consistent with prior histologic studies demonstrating regional variation in brain maturation and suggest that arterial spin-labeling is sensitive to regional as well as age-related differences in CBF in young children.

ProClust: improved clustering of protein sequences with an extended graph-based approach

MOTIVATION

The problem of finding remote homologues of a given protein sequence via alignment methods is not fully solved. In fact, the task seems to become more difficult with more data. As the size of the database increases, so does the noise level; the highest alignment scores due to random similarities increase and can be higher than the alignment score between true homologues. Comparing two sequences with an arbitrary alignment method yields a similarity value which may indicate an evolutionary relationship between them. A threshold value is usually chosen to distinguish between true homologue relationships and random similarities. To compensate for the higher probability of spurious hits in larger databases, this threshold is increased. Increasing specificity however leads to decreased sensitivity as a matter of principle. Sensitivity can be recovered by utilizing refined protocols. A number of approaches to this challenge have made use of the fact that proteins are often members of some larger protein family. This can be exploited by using position-specific substitution matrices or profiles, or by making use of transitivity of homology. Transitivity refers to the concept of concluding homology between proteins A and C based on homology between A and a third protein B and between B and C. It has been demonstrated that transitivity can lead to substantial improvement in recognition of remote homologues particularly in cases where the alignment score of A and C is below the noise level. A natural limit to the use of transitivity is imposed by domains. Domains, compact independent sub-units of proteins, are often shared between otherwise distinct proteins, and can cause substantial problems by incorrectly linking otherwise unrelated proteins.

RESULTS

We extend a graph-based clustering algorithm which uses an asymmetric distance measure, scaling similarity values based on the length of the protein sequences compared. Additionally, the significance of alignment scores is taken into account and used for a filtering step in the algorithm. Post-processing, to merge further clusters based on profile HMMs is proposed. SCOP sequences and their super-family level classification are used as a test set for a clustering computed with our method for the joint data set containing both SCOP and SWISS-PROT. Note, the joint data set includes all multi-domain proteins, which contain the SCOP domains that are a potential source of incorrect links. Our method compares at high specificities very favorably with PSI-Blast, which is probably the most widely-used tool for finding remote homologues. We demonstrate that using transitivity with as many as twelve intermediate sequences is crucial to achieving this level of performance. Moreover, from analysis of false positives we conclude that our method seems to correctly bound the degree of transitivity used. This analysis also yields explicit guidance in choosing parameters. The heuristics of the asymmetric distance measure used neither solve the multi-domain problem from a theoretical point of view, nor do they avoid all types of problems we have observed in real data. Nevertheless, they do provide a substantial improvement over existing approaches.

AVAILABILITY

The complete software source is freely available to all users under the GNU General Public License (GPL) from http://www.bioinformatik.uni-koeln.de/~proclust/download/

Metabolic pathway analysis web service (Pathway Hunter Tool at CUBIC)

MOTIVATION

Pathway Hunter Tool (PHT), is a fast, robust and user-friendly tool to analyse the shortest paths in metabolic pathways. The user can perform shortest path analysis for one or more organisms or can build virtual organisms (networks) using enzymes. Using PHT, the user can also calculate the average shortest path (Jungnickel, 2002 Graphs, Network and Algorithm. Springer-Verlag, Berlin), average alternate path and the top 10 hubs in the metabolic network. The comparative study of metabolic connectivity and observing the cross talk between metabolic pathways among various sequenced genomes is possible.

RESULTS

A new algorithm for finding the biochemically valid connectivity between metabolites in a metabolic network was developed and implemented. A predefined manual assignment of side metabolites (like ATP, ADP, water, CO(2) etc.) and main metabolites is not necessary as the new concept uses chemical structure information (global and local similarity) between metabolites for identification of the shortest path.

The relationship of sleep quality and posttraumatic stress to potential sleep disorders in sexual assault survivors with nightmares, insomnia, and PTSD

Sleep quality and posttraumatic stress disorder (PTSD) were examined in 151 sexual assault survivors, 77% of whom had previously reported symptoms of sleep-disordered breathing (SDB) or sleep movement disorders (SMD) or both. Participants completed the Pittsburgh Sleep Quality Index (PSQI) and the Posttraumatic Stress Scale (PSS). High PSQI scores reflected extremely poor sleep quality and correlated with PSS scores. PSQI scores were greater in participants with potential SDB or SMD or both. PSQI or PSS scores coupled with body-mass index and use of antidepressants or anxiolytics predicted potential sleep disorders. The relationship between sleep and posttraumatic stress appears to be more complex than can be explained by the current PTSD paradigm; and, sleep breathing and sleep movement disorders may be associated with this complexity.

Clustering protein sequences--structure prediction by transitive homology

MOTIVATION

It is widely believed that for two proteins Aand Ba sequence identity above some threshold implies structural similarity due to a common evolutionary ancestor. Since this is only a sufficient, but not a necessary condition for structural similarity, the question remains what other criteria can be used to identify remote homologues. Transitivity refers to the concept of deducing a structural similarity between proteins A and C from the existence of a third protein B, such that A and B as well as B and C are homologues, as ascertained if the sequence identity between A and B as well as that between B and C is above the aforementioned threshold. It is not fully understood if transitivity always holds and whether transitivity can be extended ad infinitum.

RESULTS

We developed a graph-based clustering approach, where transitivity plays a crucial role. We determined all pair-wise similarities for the sequences in the SwissProt database using the Smith-Waterman local alignment algorithm. This data was transformed into a directed graph, where protein sequences constitute vertices. A directed edge was drawn from vertex A to vertex B if the sequences A and B showed similarity, scaled with respect to the self-similarity of A, above a fixed threshold. Transitivity was important in the clustering process, as intermediate sequences were used, limited though by the requirement of having directed paths in both directions between proteins linked over such sequences. The length dependency-implied by the self-similarity-of the scaling of the alignment scores appears to be an effective criterion to avoid clustering errors due to multi-domain proteins. To deal with the resulting large graphs we have developed an efficient library. Methods include the novel graph-based clustering algorithm capable of handling multi-domain proteins and cluster comparison algorithms. Structural Classification of Proteins (SCOP) was used as an evaluation data set for our method, yielding a 24% improvement over pair-wise comparisons in terms of detecting remote homologues.

AVAILABILITY

The software is available to academic users on request from the authors.

CONTACT

e.bolten@science-factory.com; schliep@zpr.uni-koeln.de; s.schneckener@science-factory.com; d.schomburg@uni-koeln.de; schrader@zpr.uni-koeln.de.

SUPPLEMENTARY INFORMATION

http://www.zaik.uni-koeln.de/~schliep/ProtClust.html.

Treatment of chronic nightmares in adjudicated adolescent girls in a residential facility

PURPOSE

To evaluate imagery rehearsal therapy for the treatment of chronic nightmares in a sample of adolescent girls.

METHODS

Adolescent girls ranging in age from 13 to 18 years were recruited from the Wyoming Girls School in Sheridan, Wyoming (treatment group, n = 9; control group, n = 10). These girls had previously suffered a high prevalence of unwanted sexual experiences in childhood and adolescence, and thus many suffered from nightmares, sleep complaints, and posttraumatic stress symptoms. Imagery rehearsal therapy was provided in a 1-day (6-h) workshop. Imagery rehearsal consists of three steps, all of which are performed in the waking state: (a) select a nightmare, (b) "change the nightmare any way you wish," and (c) rehearse the images of the new version ("new dream") 5 to 20 min each day. Control participants received no intervention.

RESULTS

At baseline, these girls had been suffering from nightmares, on average, for 4.5 years, and they reported experiencing 20 nightmares per month, which occurred at a frequency of at least one bad dream every other night. At 3 months, self-reported, retrospectively assessed nightmare frequency measured in nights per month decreased 57% (p =.01, d = 1.4) and measured in nightmares per month decreased 71% (p =.01, d = 1.7) in the treatment group, compared with no significant changes in the control group. No significant changes were noted for sleep and posttraumatic stress disorder measures in either group.

CONCLUSION

Imagery rehearsal therapy was an effective treatment option for chronic nightmares in this adjudicated adolescent population.

Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial

CONTEXT

Chronic nightmares occur frequently in patients with posttraumatic stress disorder (PTSD) but are not usually a primary target of treatment.

OBJECTIVE

To determine if treating chronic nightmares with imagery rehearsal therapy (IRT) reduces the frequency of disturbing dreams, improves sleep quality, and decreases PTSD symptom severity.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial conducted from 1995 to 1999 among 168 women in New Mexico; 95% had moderate-to-severe PTSD, 97% had experienced rape or other sexual assault, 77% reported life-threatening sexual assault, and 58% reported repeated exposure to sexual abuse in childhood or adolescence.

INTERVENTION

Participants were randomized to receive treatment (n = 88) or to the wait-list control group (n = 80). The treatment group received IRT in 3 sessions; controls received no additional intervention, but continued any ongoing treatment.

MAIN OUTCOME MEASURES

Scores on the Nightmare Frequency Questionnaire (NFQ), Pittsburgh Sleep Quality Index (PSQI), PTSD Symptom Scale (PSS), and Clinician-Administered PTSD Scale (CAPS) at 3- and 6-month follow-up.

RESULTS

A total of 114 participants completed follow-up at 3 and/or 6 months. Comparing baseline to follow-up (n = 97-114), treatment significantly reduced nights per week with nightmares (Cohen d = 1.24; P<.001) and number of nightmares per week (Cohen d = 0.85; P<.001) on the NFQ and improved sleep (on the PSQI, Cohen d = 0.67; P<.001) and PTSD symptoms (on the PSS, Cohen d = 1.00; P<.001 and on the CAPS, Cohen d = 1.53; P<.001). Control participants showed small, nonsignificant improvements for the same measures (mean Cohen d = 0.21). In a 3-point analysis (n = 66-77), improvements occurred in the treatment group at 3-month follow-up (treatment vs control group, Cohen d = 1.15 vs 0.07 for nights per week with nightmares; 0.95 vs -0.06 for nightmares per week; 0.77 vs 0.31 on the PSQI, and 1.06 vs 0.31 on the PSS) and were sustained without further intervention or contact between 3 and 6 months. An intent-to-treat analysis (n = 168) confirmed significant differences between treatment and control groups for nightmares, sleep, and PTSD (all P<.02) with moderate effect sizes for treatment (mean Cohen d = 0.60) and small effect sizes for controls (mean Cohen d = 0.14). Posttraumatic stress symptoms decreased by at least 1 level of clinical severity in 65% of the treatment group compared with symptoms worsening or not changing in 69% of controls (chi(2)(1) = 12.80; P<.001).

CONCLUSIONS

Imagery rehearsal therapy is a brief, well-tolerated treatment that appears to decrease chronic nightmares, improve sleep quality, and decrease PTSD symptom severity.

Complex insomnia: insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD

BACKGROUND

Sleep disturbance in posttraumatic stress disorder is very common. However, no previous posttraumatic stress disorder studies systematically examined sleep breathing disturbances, which might influence nightmares, insomnia, and posttraumatic stress disorder symptoms.

METHODS

Forty-four consecutive crime victims with nightmares and insomnia underwent standard polysomnography coupled with a nasal pressure transducer to measure airflow limitation diagnostic of obstructive sleep apnea and upper airway resistance syndrome.

RESULTS

Forty of 44 participants tested positive on objective sleep studies based on conservative respiratory disturbance indices of more than 15 events per hour; 22 patients suffered from obstructive sleep apnea and 18 suffered from upper airway resistance syndrome.

CONCLUSIONS

In an uncontrolled study, insomnia and sleep-disordered breathing were extremely prevalent in this small and select sample of crime victims. Research is needed to study 1) prevalence of sleep-disordered breathing in other posttraumatic stress disorder populations using appropriate controls and nasal pressure transducers and 2) effects of sleep treatment on posttraumatic stress symptoms in trauma survivors with comorbid obstructive sleep apnea or upper airway resistance syndrome. In the interim, some posttraumatic stress disorder patients may benefit from sleep medicine evaluations.

Catheter closure of atrial septal defects and patent foramen ovale in patients with an atrial septal aneurysm using different devices

BACKGROUND

Atrial septal aneurysm is frequently associated with patent foramen ovale (PFO) and atrial septal defects (ASD). Moreover, a relationship between atrial septal aneurysm and embolic cerebrovascular events has been suggested. The aims of this study were to analyze morphological and functional characteristics of atrial septal aneurysm in PFO and ASD patients and to assess the feasibility and efficacy of different devices for transcatheter closure and the influence of atrial septal aneurysm.

METHODS

Between March 1997 and May 2000 transcatheter ASD or PFO closure was attempted in 63 patients (mean age 47 +/- 13 years) with an atrial septal aneurysm using one of the following devices: Angelwings (n = 3), Cardioseal (n = 5), Cardioseal-Starflex (n = 7), Amplatzer (n = 11), Amplatzer-PFO (n = 5), PFO-Star (n = 25), or Helex (n = 7).

RESULTS

Implantation was primarily successful (after the first or second attempt) in all patients. One PFO-Star device embolized 12 hours after the procedure. During follow-up (0.6-37 months, mean 10.4 +/- 9.2) a residual shunt could be detected by transesophageal echocardiography after 2 weeks in four patients and after 6 months in one patient. Three PFO patients had cerebrovascular events after implantation. Two patients had a transient ischemic attack (TIA) and one patient a stroke. A thrombus formation on the device detected in three patients disappeared after antithrombotic therapy.

CONCLUSION

We conclude that ASDs and PFOs with an associated atrial septal aneurysm can be closed with different available devices. There seem to be no additional risks compared with patients without atrial septal aneurysm.

A controlled study of imagery rehearsal for chronic nightmares in sexual assault survivors with PTSD: a preliminary report

Imagery-rehearsal therapy for chronic nightmares was assessed in a randomized, controlled study of sexual assault survivors with posttraumatic stress disorder (PTSD). Nightmares, sleep quality, and PTSD were assessed at baseline for 169 women, who were randomized into two groups: treatment (n = 87) and wait-list control (n = 82). Treatment consisted of two 3-hr sessions and one 1-hr session conducted over 5 weeks. Of 169 participants, 91 women (Treatment, n = 43, Control, n = 48) completed a 3-month follow-up and 78 did not. At follow-up, nightmare frequency and PTSD severity decreased and sleep quality improved in the treatment group with small to minimal changes in the control group. Treatment effects were moderate to high (Cohen's d ranged from 0.57 to 1.26). Notwithstanding the large dropout rate, imagery-rehearsal therapy is an effective treatment for chronic nightmares in sexual assault survivors with PTSD and is associated with improvement in sleep quality and decreases in PTSD severity.

Sleep breathing and sleep movement disorders masquerading as insomnia in sexual-assault survivors

A descriptive, hypothesis-generating study was performed with 156 female sexual-assault survivors who suffered from insomnia, nightmares, and posttraumatic stress disorder (PTSD). They completed 2 self-report sleep questionnaires to assess the potential presence of intrinsic sleep disorders. Seventy-seven percent of the sample (120 of 156) endorsed additional sleep complaints, besides their insomnia symptoms, that indicate the potential presence of sleep-disordered breathing ([SDB] 81 of 156, 52%) and sleep-related movement disorders ([SMD] 94 of 156, 60%). The potential for SDB was strongly correlated with the body mass index (BMI), an increase in arousal symptoms, and greater total PTSD severity. In some sexual-assault survivors, the relationship between sleeplessness and posttraumatic stress may be caused or exacerbated by intrinsic sleep disorders, and not be solely a function of psychophysiological insomnia--the traditional diagnostic term usually offered to explain the sleep problems associated with PTSD. Prevalence studies that use objective diagnostic evaluations such as polysomnography (PSG) are needed to test these hypotheses.

A canine model of familial mammary gland neoplasia

Intact female Beagles from life-span studies in the Lovelace Respiratory Research Institute colony were examined for mammary tumor incidence. The breeding colony, founded in 1963, produced five generations from 28 founder females. After proportional hazards analysis, two maternal families were shown to have markedly different phenotypes, one susceptible and one resistant to mammary neoplasia, as compared with the entire colony. When tumors were subdivided into benign and malignant based on local invasiveness, familial differences in tumor incidence were preserved for each tumor type. Fifty-seven females in the susceptible family developed 149 benign and 39 malignant tumors, and 95 females in the resistant family developed 70 benign and 20 malignant tumors. The ratio of benign to malignant tumors of about 4:1 for both families was higher than expected. Using Kaplan-Meier and log-rank analyses, the susceptible family had a 50% malignant tumor incidence by age 13.6 years, whereas the resistant family did not have a 50% incidence until 17.0 years (P = 0.0065). Because of marked censoring, Kaplan-Meier analyses could not provide an estimate of the 50% benign tumor incidence; mean incidence age was calculated instead. These estimates for benign tumors for susceptible and resistant families were 10.8 and 13.8 years (P = 0.0001), respectively. Using chi(2) tests, families had no differences in the occurrence of the types of benign (P = 0.098) or malignant (P = 0.194) tumors or in the ratio of benign to malignant tumors (P = 0.778). Immunohistochemical analysis of malignant tumors from both families did not demonstrate differences in p53 mutation rate or p185erbB-2 expression. These results suggest that 1) genetic factors produce familial differences in the age of onset of both benign and malignant mammary tumors; histologic types do not segregate by family; 2) the ratio of benign to malignant tumors is greater than formerly reported; and 3) neither p53 nor p185erbB-2 alterations are the basis for the familial predisposition.

[Use of a fast test to detect rotavirus in feces]

The commercially available immunoassay "OnSite Rotavirus" was used for the detection of animal rotaviruses in 113 faecal samples. The sensitivity of the test was 88% and the specificity 96% compared with reference methods (EIA, EM). This test would detect approximately 4.4 x 10(6) to 1.8 x 10(7) virus particles per ml. The presence of virus could be demonstrated in fresh faecal samples from cattle, horses and pigs within a few minutes. The rotaviruses of group A were identified independently of the virus serotype. Further results and additional problems of using this test kit are described.

The developmental potential of the human oocyte is related to the dissolved oxygen content of follicular fluid: association with vascular endothelial growth factor levels and perifollicular blood flow characteristics

Regardless of whether fertilization occurs in vivo or in vitro, a large proportion of human embryos do not develop progressively through the pre-implantation stages or arrest development after implantation. This study examined the association between the chromosomal/spindle normality of the mature human oocyte and the dissolved oxygen content, vascular endothelial growth factor concentration (VEGF) and perifollicular blood flow characteristics of the corresponding ovarian follicles. Findings from >1000 samples of follicular fluid show that developmentally significant differences in dissolved oxygen content occur in follicular fluids aspirated from follicles of equivalent size and ultrasonographic appearance. Oocytes from severely hypoxic follicles were associated with high frequencies of abnormalities in the organization of the chromosomes on the metaphase spindle that could lead to segregation disorders and catastrophic mosaicisms in the early embryo. Oocytes with cytoplasmic defects and cleavage stage embryos with multinucleated blastomeres are derived predominantly from severely hypoxic follicles. VEGF measurements of follicular fluid and colour pulsed Doppler ultrasonographic analysis of follicle-specific blood flow characteristics indicated a potentially important role for this factor both in perifollicular angiogenesis and in the regulation of intrafollicular oxygen levels. The results are discussed with respect to how severe intrafollicular hypoxia may influence the normality of chromosomal organization and segregation in the oocyte, and whether detailed pulsed Doppler analysis of individual pre-ovulatory follicles may provide an indirect indication of the 'health' of the follicle and possibly the developmental competence of the corresponding oocyte.

[Measurement of the distance of the rectal mucosa from a gynecologic afterloading applicator based on the drop in performance of a cobalt-60-source]

PURPOSE

Assessment of the distance from a gynecological afterloading applicator to the rectum mucosa.

METHODS

The appropriate afterloading applicator for HDR-Ir-therapy is used for that purpose. A Co-60-source (370 MBq) with a guiding wire is positioned at the tip of the applicator and then withdrawn in steps of 1 cm. For each of these points the maximum dose at the rectum mucosa is measured with an ionisation chamber. From a reference curve it is then possible to determine the distance from the rectum mucosa to the applicator and to mark it in the calculated isodose plan. The actual daily dose to the rectum mucosa is planned not to exceed 3.0 Gy in the maximum.

RESULTS

Up to now the measurements were performed in 91 patients. The minimal distances of the rectum mucosa from the applicator were found to range from 5 to 18 mm with an average value of 14 mm.

CONCLUSIONS

The comparison of the measurement with the readings of the rectum probe during each session showed, that the method is suitable to avoid an overdose at the rectum mucosa.

[Stomatological identification after air disasters]

The paper describes experiences of stomatological identification after two air disasters and shows potentialities and limits of an odontologic(al) comparison. The application of a 16-bit-computer is pointed out as the essential improvement of the work.

[Dose distribution of pendulum fields in the field border plane]

Calculations (program SIDOS-U2) and LiF measurements taken in a cylindric water phantom are used to investigate the isodose distributions of different pendulum irradiation methods in a plane which is parallel to the central ray plane and crosses the field borders at the depth of the axis. The dose values compared to the maximum values of the central ray plane are completely different for each pendulum method. In case of monoaxial pendulum methods around small angles, the maximum dose value found in the border plane is less than 50% of the dose in the central ray plane. The relative maximum of the border plane moves to tissues laying in a greater depth. In case of bi-axial methods, the maximum value of the border plane can be much more than 50% of the maximum dose measured in the central ray plane.

[Effect of satellite supports of different materials on the surface dose in telecobalt therapy]

The surface doses were measured behind shield supports of different materials with a focus-skin distance of 140 cm. The shield supports were at a distance of 40 cm from the skin. The plates were made of lead glass with a thickness of 11.3 mm, window glass with a thickness of 2.6 mm, plexiglas with a thickness of 5 and 10 mm, and perforated plexiglas with a thickness of 6 mm. The greatest contamination of the useful ray with secondary electrons was measured behind the plexiglas plates, the least contamination was measured behind the plate of lead glass. The relative surface dose is increased by at most 18.5% by plates of plexiglas, while the lead glass plate causes an increase of 3.3%.

[Dosage of conservative therapy of the mammary carcinoma by means of opposing Co-60 wedge filter fields (author's transl)]

A method of measurement is described which allows to determine the maximum dose (tumor dose) for routine radiotherapy of the breast with opposing Co-60 wedge filter stationary fields. Furthermore it could be demonstrated that--independently of the form of the mamma--a sufficiently precise dosage can also be achieved by means of a simple calculation. For this purpose one must only know the base (= distance of the dorsal field marks on the skin) and the irradiation time for the dose to be applied into the depth dose maximum of a rectangular stationary field without filter.

[Surface dose reduction achieved by means of a lead glass filter in case of teletherapy with Co 60 radiation (author's transl)]

The surface dose of irradiated patients can be reduced by the insertion of a lead glass filter with a thickness of 4 mm at the ray emergence point of a Co 60 gammatron. The lead glass which is made stable against color alterations by radiation, will absorb the secondary electrons produced by the gamma radiation at the collimator and shutter system of the gammatron. The filter allows to reduce the surface dose in a tissue depth of 0,05 to 0,1 mm by a maximum rate of 16% according to the size of the irradiation field. Measurements were taken with a soft radiation chamber in several tissue depths within and outside the field using three different filtering methods (without any filter, 1 mm plexiglas, 4 mm lead glass). There are essential advantages for teletherapy of deep tumors by the use of a lead glass filter, so that the insertion of such a filter is recommended for all Co 60 units.

[Irradiation planning in conservative treatment of cancer of the breast (author's transl)]

Investigations of homogeneous irradiation of the breast with opposed wedge filter fields are presented. Isodose plans calculated with the help of computer programs were compared with measurements of isodose distributions (LiF rods in polystyrol phantoms), and the possibility of optimizing the irradiation method by means of computed plans was examined. Differences between the calculated and the measured values maximally amounted to 10% (programs SIDOS U2 and COMRAD). The calculations correctly describe the place of dose maxima, the homogeneity of the irradiation and tendency to isodose shift caused by variation of the shape of the breast, of the angle of incidence of radiation and of the angles of the wedges. The results are demonstrated using isodose lines in the mediolateral and in the craniocaudal plane of the breast.

[Reduction of the surface dose of Co 60 rays in a tissue depth of 0 to 3 mm by means of a magnetic field (author's transl)]

In an air gap of 10 centimeters of width lying over a U-shaped iron core, a magnetic field with an intensity of B greater than or equal to 0,069 Tesla is produced by two permanent magnetic plates. This field is arranged behind the diaphragm unit of a Co-60 gammatron at right angle to the direction of radiation, so the surface dose can be reduced until a depth of 3 millimeters. This magnetic field diffracts the secondary electrons emanating from the diaphragms of the gammatron in such a manner that they cannot contribute to the surface dose within or beyond the irradiation field. Depending on the size of the irradiation field, the magnet allows to reduce the dose by 30% at most in a tissue depth of 5 to 10 mg/cm2. Measures were taken by means of a soft radiation chamber for different tissue depths within and beyond the irradiation field.

[The dosage for tangential pendulum irradiation of the thoracic wall using 60Co in surgically treated cancer of the breast and the irradiation of the parasternal lymph nodes (author's transl)]

The determination of the dose to the patient during excentric pendulum irradiation of the thoracic wall is described. The dose delivered in the course of irradiation is simultaneously measured at the patient's surface, using a measuring system with LiF-rods which was especially developed for this purpose. The value obtained has to be multiplied with a correction factor FK=0.96 in order to yield the maximum dose, being located at a depth of 2.5 mm below the skin. The accuracy of this method for determination of doses is discussed, and the deviations are shown not to exceed 5 or 6% of the total dose. The dosage by means of tube chamber measurement is represented as an alternative method. The parasternal lymph nodes are irradiated, in addition to the dose from pendulum irradiation, with a fixed field and employing a lead wedge, both lymphatic chains thus receiving a homogeneous dose.

[Tangential pendulum irradiation of the thoracic wall with co-60 during radiation therapy of surgically treated cancers of the breast: comparison of measurement and computation methods for irradiation planning (author's transl)]

The irradiation technique for tangential pendulum 60-Co-irradiation of the thoracic wall is described, and the possibility of a homogeneous irradiation of the thoracic region of interest by means of individual irradiation planning together with a careful, but practicable, technique of positioning and adjustment is shown. The radiation load to the lung can be kept on a moderate level. Phantom measurements with thermoluminescence probes, films and an ionization chamber have been performed for three typical forms of the thorax. Dose distributions thus obtained show a satisfying accordance with calculated values of the dose, the deviations amounting to 3 to 8%. The EDP program applied, COMRAD, thus permits computation of individual pendulum isodoses with sufficient accuracy in practice, and therefore, may be used regularly.

[Comparison of measured relative isodose distributions in tangential stationary fields of Co-60 radiation with calculated isodose plans (author's transl)]

The relative isodose distributions in tangential stationary fields are measured in rectangular phantoms by means of four different methods: film measurements, thermoluminescence probes, ionization chamber, and semiconductor probes. The different measuring methods are compared, and the influence exercised by the part of the field running in the air is examined. Within the scope of their applicability, all measuring methods produce the same values which differ only by +/- 1%. It is possible to reach a better estimation of the dose distribution in the depth of the "partial fields" (a part of which is running in the air) by reducing adequately a "complete field". Furthermore, isodose distributions of measured "partial fields" are compared with calculations from a programme for the irradiation planning (programme COMRAD), and they are discussed. It is shown that the losses due to scattered radiation are not rendered by the calculation.